Galactorrhea: a complication of spinal cord injury.

Galactorrhea, a secretion of milk or milk-like products from the breast in the absence of parturition, has been reported to occur in women with spinal cord injuries in association with amenorrhea and hyperprolactinemia. Four cases of galactorrhea in association with spinal cord injury are reported. Galactorrhea developed in four spinal cord injured women who had thoracic paraplegia. The onset of galactorrhea was from one month to five months after injury. Although the onset of galactorrhea may have been related to prescribed medications in all four cases, insufficient data exist to draw conclusions. The three women whose galactorrhea persisted declined treatment and galactorrhea continuing for more than two years in one instance. We conclude that galactorrhea with or without amenorrhea may develop after a spinal cord injury and that spinal cord injured women may have an enhanced sensitivity to medication-induced galactorrhea.

Classification of pressure ulcers.

Several systems exist for classifying pressure ulcers, though none of them have been evaluated for interrater reliability. A new grading scale was compared with the commonly used Shea classification. This new scale was developed to provide a more complete description of pressure ulcer healing. The advantages of this scale include a classification of red areas as ulcers to help prevent further deterioration and classification of healed sores to note potential problems. The Yarkony-Kirk scale classifies a red area as a grade 1 ulcer, and involvement of the epidermis and dermis with no subcutaneous fat observed as a grade 2 ulcer. Grade 3 indicates exposed subcutaneous fat with no muscle observed. Exposed muscle without bone involvement is classified as a grade 4 ulcer, and grade 5 describes exposed bone with no joint space involvement. Grade 6 indicates joint space involvement. There is a classification of pressure sore healed to indicate a healed pressure ulcer. Interrater reliability was assessed by two nurses. In spite of an increased number of categories for the Yarkony-Kirk scale, there was no decline in reliability. Reliability was excellent with an interrater correlation of 0.90 for the Yarkony-Kirk scale and 0.86 for the Shea classification when measured for 72 patients. Eighty-five percent of the ratings for the Yarkony-Kirk scale were identical, whereas only 68% were identical for the Shea classification. Three percent of the ratings for the Shea classification were greater than +/- 1 category; 6% of the ratings for the Yarkony-Kirk scale were greater than +/- 1 category. This scale appears to possess good reliability and to describe pressure ulcers more completely. This scale may also be used to teach prevention activities as well as ulcer classification.

Spinal cord injury care system: fifteen-year experience at the Rehabilitation Institute of Chicago.

A statistical study of 15 years of the spinal cord injury care system of the Rehabilitation Institute of Chicago is reported. The Rehabilitation Institute of Chicago (RIC) is the rehabilitation component of the Midwest Regional Spinal Cord Injury Care System, a collaborative programme with Northwestern Memorial Hospital and Northwestern University. Data are reported on 1382 patients, a representative sample of the over 2000 patients treated since the inception of the centre. The sample was predominantly male (83%, N = 1147) and caucasian (64%, N = 888). The most common aetiology was motor vehicle accidents (36%, N = 505). During the 15-year period there were significant decreases in both acute and rehabilitation lengths of stay. Ninety three per cent of the patients were discharged home. Rehabilitation benefits were demonstrated by improvements in the Modified Barthel Index. The research, educational and clinical programmes are described.

Risk factors for heterotopic ossification in spinal cord injury.

Heterotopic ossification (HO) is a complication in 16% to 53% of spinal cord injured (SCI) patients. One third of these patients have moderate to severe HO that adversely affects function or health. Pharmacologic prophylaxis of HO for all SCI patients continues to be controversial. High-risk criteria for HO formation identified in total hip replacement patients are not applicable to SCI. A review of the literature did not reveal specific risk factors for HO with SCI. The charts of 100 randomly selected SCI patients, 50 with HO and 50 without HO, were reviewed retrospectively to learn if criteria which would predict high-risk patients could be identified. A total of 14 variables, seven demographic (age, sex, race, level of lesion, completeness of lesion, cause of injury, and geographic locus of patient) and seven medical (bladder stones, fractures, pressure sores, deep vein thrombosis, pulmonary embolism, spasticity, and urinary tract infections) were studied. Four of the 14 variables (age, completeness of lesion, presence of pressure sores, and spasticity) were significantly related to HO formation. The risk factors appear to be additive. When all were present, 92% of patients were found to have HO. Before the findings are applied clinically, it is suggested that a prospective study be conducted to confirm the risk predictive value of these factors in HO.

Prospective payment for acute care: impact on rehabilitation hospitals.

This study assessed rehabilitation workers' perceptions of acute care Medicare prospective payment effects on rehabilitation hospitals and units. Members of four groups--physicians, nurses, social workers, and administrators--were asked to complete a survey of prospective payment effects. All survey participants worked at one of the 373 DRG-exempt rehabilitation hospitals in 46 states that have similar prospective payment systems. A total of 761 persons (60% of the eligible sample) responded with complete answers. Across all groups, respondents reported increases in the frequency of acute illness, as well as increases in complications and readmission into acute care. An increase in the number of referrals for inpatient rehabilitation was also reported, although only minimal changes in the length of rehabilitation stay were perceived. Individuals at rehabilitation hospitals perceived a greater increase in complication and readmission rate and acute illness, whereas individuals at rehabilitation units perceived a greater increase in referrals. Differences among members of the four disciplines were small, with social workers reporting the largest increase in complications and readmission to acute care hospitals, as well as in referrals for inpatient rehabilitation. Implications of these findings for rehabilitation hospitals and units are discussed.

Multivariate analysis of improvement and outcome following stroke rehabilitation.

This study documented the status of 432 patients and characteristics of functional improvements and outcomes achieved by 163 patients who participated in comprehensive stroke rehabilitation. Scores on the 100-point Activities of Daily Living Index improved from hospital admission to discharge and declined slightly at follow-up. An average Activities of Daily Living Index point gain of 0.6 per day was found that was unrelated to age, sex, side of hemiparesis, or admission functional status. Seventy-nine percent of the patients were discharged home; 85% were home at follow-up. Eleven percent of the patients were working at follow-up. Patients traveled outside their homes an average of 24.6 days during the three months immediately following discharge. A significant number of patients achieved favorable functional housing, employment, and social outcomes. This study supported referral for rehabilitation services regardless of age, side of hemiparesis, or degree of impairment.

Rehabilitation of craniocerebral trauma.

Rehabilitation of the craniocerebral trauma patient is an increasing challenge worldwide. The return of these individuals to society requires the foresight to begin rehabilitation efforts as soon as the patient receives medical attention. This article reviews the spectrum of medical, physical, and social problems associated with craniocerebral trauma and provides guidelines for the rehabilitation process.

RIC-Wu catheter kit: new device for an old problem.

A new catheter kit has been developed for sterile urethral catheterization. It is useful for any patient requiring catheterization but has special advantages for the spinal cord injured person with a neurogenic bladder. The RIC-Wu Catheter Kit is simply a straight rubber catheter contained in a sterile clear plastic bag with one end formed into a restricted sterile field and the other into a tear-off chamber for urine laboratory testing. In clinical trials the RIC-Wu Catheter Kit has been found to have several advantages over the conventional sterile catheter tray: staff or self-catheterization is usually easier, faster and can be carried out with the patient sitting in a wheelchair in any private place; it is pocket sized and can be less expensive; less professional staff time is expected for a catheterization program; catheterization-induced infection rates are expected to be the same or less.

An innovative removable rigid dressing technique for below-the-knee amputation.

The below-the-knee removable rigid dressing is a below-the-knee plaster cast held by a suspension stockinette to a supracondylar plastic cuff. It has proved to be an effective method for postoperative, pre-prosthetic, and prosthetic care of below-the-knee amputees. Being removable, it permits frequent observation and progressive shrinkage of the stump (by adding socks), and eliminates the need of elastic stump bandaging. In addition, it still maintains the advantages of immobilization of soft tissue (to reduce pain and facilitate wound healing) and prevention of trauma to the stump as does the conventional rigid dressing. It has significantly reduced the incidence of pre-tibial skin breakdown and distal edema, produced fast stump shrinkage, and shortened time to ambulatory discharge with a temporary prosthesis by ninety days.

Sinography in management of decubitus ulcers.

Draining sinuses are considered a major complication of decubitus ulcers in spinal cord injury patients. Of 144 such patients with decubitus ulcers admitted in 1975 and 1976, 15 had draining sinuses. Twenty-one sinograms were obtained in the process of their evaluation prior to treatment. In 6 patients, sinography resulted in unexpected findings such as excessive depth of the sinus tract, abscess formation, undermining of previous graft, and extension into neighboring joints, affecting both the management of the decubitus ulcers and the surgical approach. It is concluded that sinography should become an integral part of management of decubitus ulcers with draining sinuses.

Stroke and brachial plexus injury: a difficult problem.

Five patients are presented, all of whom had middle cerebral artery syndrome with hemiplegia on the contralateral side. All five had electromyographic evidence consistent with neuropathy involving the upper trunk of the brachial plexus on the side affected by the stroke. All patients were exposed to intensive rehabilitation team effort involving range of motion, strengthening exercises, positioning, splinting, coordination exercises and exercises designed to increase ability at arm placement. Three patients regained EMG evidence of innervation of the shoulder girdle muscles after more than eight months, during which time a rehabilitative effort was made. The other two patients have not yet regained control over the muscles of the shoulder girdle by EMG or clinical criteria. The EMG evidence of brachial plexus injury in those patients who eventually showed reinnervation took 8 to 12 months to resolve. The rehabilitation of the patients with stroke involving the upper extremity may have been set back significantly as a result of the neuropathy. It is suggested that patients with stroke and brachial plexus injury probably will have a more arduous and prolonged course in rehabilitation of the upper extremity as a result.

Lupoid sclerosis: evaluation and treatment.

The history, physical examination and laboratory data are presented of a patient with multiple sclerosis and systemic lupus erythematosus. The rehabilitation medicine evaluation and course of therapy are reviewed. Other published cases of similar patients are reviewed.